General questions about SLEEPexpert
What is the aim of SLEEPexpert?
SLEEPexpert is an adaptation of Cognitive Behavioral Therapy for Insomnia (CBT‑I) tailored to routine clinical care. It equips healthcare professionals with a practical and structured treatment programm to support the sleep health of their patients.
Which fundamental processes of sleep regulation is SLEEPexpert based on?
SLEEPexpert is based on two fundamental processes of sleep regulation: sleep-wake behavior (homeostatic) and daily rhythm (circadian).
A sufficient period of wakefulness is necessary to build up enough sleep pressure to initiate and maintain sleep. This is supported by a circadian decline in the wake-promoting signal in the late evening (decreasing evening wake maintenance zone). Conversely, toward the end of the night and early morning, a circadian sleep-promoting signal helps maintain sleep (sleep maintenance phase). Healthy sleep results from the interaction of these two processes—sufficient sleep pressure and alignment with an appropriate circadian phase.
What is the Insomnia Severity Index (ISI)?
The Insomnia Severity Index (ISI) is a questionnaire used to assess the severity of insomnia symptoms. It can be completed by patients in just a few minutes. A total score of ≥ 8 indicates clinically relevant insomnia symptoms. Due to copyright regulations, the questionnaire cannot be provided here. For more information: contact@sleepexpert.ch.
Who can benefit from SLEEPexpert?
SLEEPexpert is deliberately designed with minimal exclusion criteria; in particular, a specific comorbid condition is not considered an exclusion criterion. To participate in the program, insomnia symptoms should be at least partially independent of any other acute disorder or substance use, or the symptoms are so severe that they cannot be fully explained by another health condition.
What are the diagnostic criteria for insomnia disorder?
The diagnostic criteria for insomnia disorder, according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM‑5) and the International Classification of Diseases, 11th Revision (ICD-11), are as follows:
A. A predominant complaint of dissatisfaction with sleep quantity or quality, associated with one or more of the following symptoms:
1. Difficulty falling asleep
2. Difficulty maintaining sleep, characterized by frequent awakenings or problems returning to sleep after awakenings
3. Early morning awakening with inability to return to sleep
B. The sleep disturbance causes clinically significant distress or impairment in social, occupational, educational, or other important areas of functioning.
C. The sleep difficulty occurs at least several nights per week.
D. The sleep difficulty has been present for at least 3 months.
E. The sleep difficulty occurs despite adequate opportunity to sleep.
F. The insomnia is not better explained by and does not occur exclusively during the course of another sleep-wake disorder.
G. The insomnia is not attributable to the physiological effects of a substance (e.g., a drug or medication).
H. Coexisting mental and physical disorders do not adequately explain the insomnia.
What is CBT‑I?
Cognitive Behavioral Therapy for Insomnia (CBT‑I) is a combination treatment that includes behavioral changes, relaxation techniques, and modification of unhelpful thoughts related to sleep. Within this approach, therapists provide psychoeducation and recommend specific changes in behavior to improve sleep.
What is bedtime restriction?
Bedtime restriction refers to the deliberate reduction of time spent in bed, with the goal of minimizing unpleasant wakefulness and promoting a more consolidated and efficient sleep period.
What is a sleep window?
A sleep window is a defined time frame for sleep with a set bedtime and wake-up time (e.g., 11.30 p.m. to 6.00 a.m.). The duration of the sleep window is adapted to the individuals reported sleep time. The timing is based on personal preferences as well as other individual factors and obligations.
When is treatment with SLEEPexpert not recommended?
Is the insomnia disorder entirely attributable to another acute medical condition or substance use (e.g., in the context of an acute psychosis or a withdrawal syndrome) and is highly likely to remit as the underlying condition improves, a separate treatment with SLEEPexpert may not be necessary and should be evaluated based on clinical judgment.
What should I be cautious about when treating patients with bipolar, psychotic disorders, or unstable somatic conditions?
Special caution is required when treating patients with bipolar or psychotic disorders, as well as those with unstable somatic illnesses. Sleep deprivation (a side effect of bedtime restriction) can trigger changes in mood episodes or decompensation. In these cases, bedtime restriction should be approached cautiously and closely monitored. It should be emphasized, that the program does not aim to reduce total sleep time, but rather to reduce unpleasant time in bed, thereby promoting better—and possibly even longer—sleep.
Is it necessary for patients to discontinue their sleep medication to participate in the program?
In principle, patients can participate with or without medication. However, participation is only meaningful if there is a current dissatisfaction with sleep. Patients who are satisfied with their sleep while on medication will not benefit from bedtime restriction. In this case, the medication would need to be reduced first. Patients who continue experiencing poor sleep despite medication do not have to stop or reduce their medication to take part in the SLEEPexpert program. It is recommended, however, to regularly review the sleep medication dosage and reduce and discontinue if possible.
What can I do in case of non-response?
Like any therapy, SLEEPexpert does not work equally well for all patients. If patients report no improvement during the program, check whether the sleep window has been consistently implemented to allow for change. Often, it turns out that the sleep window was not regularly adhered to (e.g., longer time in bed on weekends or daytime naps). As a rule of thumb, bedtime restriction should be implemented for at least 4 weeks. If there is no response after this period, possible reasons should be evaluated and further diagnostics made. This should include assessment for sleep apnea syndrome, restless legs syndrome, periodic limb movements and circadian rhythm disorders. Additionally, other somatic or psychiatric differential diagnoses should be reconsidered and specific treatments initiated if needed. According to treatment guidelines, medication can be considered in case of non-response.
What additional information does the SLEEPexpert book provide?
The most important section of the book is the SLEEPexpert treatment manual, which offers a step-by-step guide—from indication and practical implementation to discussing challenging therapy situations.
The book gives a comprehensive introduction to the fundamentals of sleep and sleep regulation, insomnia disorder and cognitive behavioral therapy for insomnia (CBT‑I). The introduction provides a better understanding of the development and aims of the program, and is essential for ensuring treatment quality.
Who can I contact for more information?
For any further questions, please contact: contact@sleepexpert.ch
Situations within the treatment team
What to do if team members say they have “no time” to deal with patients’ sleep problems?
Systematic screening for insomnia disorder and implementing the program will encourage team members to exchange information and thus promote treatment. Sleep difficulties are typically already a common topic in medical settings, requiring resources and much attention from the treatment team. Therefore, implementing the SLEEPexpert program should not create additional workload but the contrary. Once introduced and established, it can help manage sleep difficulties of patients more efficiently.
What to do to counteract the uncritical prescription of hypnotics?
A major challenge to the success of behavioral therapy for insomnia is the frequent (over)prescription of sleep-inducing medication (hypnotics) in clinical practice. The prescription or increase of hypnotics often renders previous efforts of non-pharmacological therapy by the treatment team and the patient ineffective and wastes resources. This does not only lead to frustration within the team but also shapes expectations towards treatment — namely the assumption that behavioral changes cannot improve sleep. This weakens the patients’ sense of self-efficacy. Therefore, it is of great importance that the entire treatment team is familiar with and supports the program.
Therapy situations with patients
What to do if patients are unable to report their usual bed times and sleep duration?
To determine the sleep window, average values of bed times and sleep duration are needed. However, some patients may be unable to reliably report their sleep-wake behavior — for example, due to acute crises, substance use, or severe illness-related symptoms that cause a disrupted and irregular sleep rhythm. If patients have only recently been admitted or are unable to provide accurate information, an initial sleep window is estimated, and a sleep diary is kept in parallel. Based on the diary data and ongoing communication with the patient, the sleep window is then adjusted and optimized.
How can I support patients who spend very long periods in bed?
Patients often report extended bedtimes of more than 12 hours, especially in the inpatient setting. This is particularly pronounced in certain disorders, such as depression or anxiety disorders. For the intervention to be effective, it is very important that time before and after the sleep window is spent outside of the bed. The “surfer image” from the kick-off session can be used to illustrate the mechanism of sleep pressure and to discuss individual behavior. If patients have difficulty getting out of bed despite strong motivation, document this, discuss it within the treatment team, and potentially address it together with the patient so that the entire treatment team can provide further support.
How can patients spend the additional time outside of bed?
When patients implement a sleep window adapted to their current sleep time, more time must be spent outside of bed. A common feedback from patients is that the bed/bedroom is their only place of retreat. Some patients may need motivation to get up and spend time outside of bed. An individualized daily routine can support this. Help your patients find activities that distract them from going back to bed and identify a space outside of the bedroom where they feel comfortable.
Can SLEEPexpert help when external factors disturb sleep?
Patients often report difficulties falling asleep and staying asleep. Upon closer inquiry, external factors can sometimes be the cause. Simple solutions such as earplugs or a sleep mask can sometimes help in these cases. Assessing the cause is important because difficulties falling or staying asleep that do not meet diagnostic criteria of insomnia disorder are not necessarily improved by the program.